Arthroscopic shoulder surgery for the treatment of rotator cuff tears: why, when and how it is done.

Edited By: Christopher J. Wahl, M.D., Suzanne L. Slaney, PA-C, ATC, MMS
Last updated Tuesday, May 16, 2006

Considering surgery

Who should consider arthroscopic rotator cuff repair and shoulder surgery for rotator cuff tears, arthroscopic, minimally-invasive and open management and in what cases?

Arthroscopic or open shoulder surgery is considered for cuff tears when:

• pain, weakness, and disability represent a significant problem for the patient, and inhibit his or her ability to perform the activities of daily living, overhead activities, or sporting activities
• the patient is sufficiently healthy to undergo the procedure
• the patient understands and accepts the risks and alternatives to the procedure
• the patient has truly exhausted non-operative treatments, like physical therapy
• an appropriate and comprehensive diagnostic evaluation has been performed and the nature of the problem is clear
• the surgeon is experienced and familiar with several techniques and treatments for shoulder injuries, including arthroscopic surgery and open (traditional surgery)
• the patient is capable and willing to undergo a comprehensive post-operative rehabilitation (physical therapy) program
• the patient does not gain financially from remaining disabled or injured (e.g. lawsuits, disability)

The results of arthroscopic and open rotator cuff repair procedures are most effective when the patient follows a simple post-operative rehabilitation program. Thus, the patient’s motivation and dedication are important elements of the partnership.

What happens if nothing is done for rotator cuff tears, arthroscopic, minimally-invasive and open management (best case/worst case scenarios)?

Persons who suffer from pain, weakness and muscular imbalances in the shoulder may lose valuable time from work, become progressively disabled, or worse: do permanent or irreparable damage to the rotator cuff or develop premature arthritis.

It is impossible to predict whether a person who first presents with short-term pain and disability from a rotator cuff injury or tear will improve without surgery.  Except in rare instances, an experienced physician or surgeon will first try to rehabilitate the shoulder with an intensive physical therapy program.  If the function of the rotator cuff can be balanced, many people will avoid the need for surgery.

In cases of an extremely long-standing rotator cuff tear with shoulder dysfunction, arthritis can occur in the shoulder joint.  This process is called rotator cuff arthropathy and can lead to severe disability and irreversible changes to the shoulder joint.  Usually, if the process has gone unchecked for a long time, a rotator cuff repair is unlikely to be successful.  Other surgical operations, involving replacement of the humeral head (also called hemi-arthroplasty) may be required to alleviate symptoms.

What options exist for surgery for rotator cuff tears, arthroscopic, minimally-invasive and open management?

In the hands of a surgeon who is experienced with arthroscopic shoulder surgery, almost all of the following procedures can be performed alone or together to restore strength and eliminate pain in the shoulder joint or from the rotator cuff:

• repair of the rotator cuff
• repair of the biceps tendon or anchor
• removal of “bone spurs” from the undersurface of the acromial roof (subacromial decompression)

When performed by an experienced surgeon, how effective is arthroscopic rotator cuff repair and shoulder surgery for rotator cuff tears, arthroscopic, minimally-invasive and open management likely to be and how long will the benefit last?

In the hands of an experienced surgeon, arthroscopic rotator cuff repair can be very effective in eliminating pain and restoring strength and function to the shoulder of a well-motivated patient. The greatest benefits are often the ability to perform the usual activities of daily living, overhead activities, and sports without discomfort, and to sleep without a chronic ache in the shoulder.  As long as the shoulder is cared for properly and subsequent traumatic injuries are avoided, the benefits of repair should be permanent.

How urgent is arthroscopic rotator cuff repair and shoulder surgery for rotator cuff tears, arthroscopic, minimally-invasive and open management?

The repair of the rotator cuff is never an emergency, and probably shouldn’t be considered until a comprehensive rehabilitation program has been attempted. There are a few exceptions to this philosophy:

• young persons in whom an MRI-documented rotator cuff tear has occurred as a result of a traumatic injury
• heavy laborers or overhead athletes in whom an MRI-documented rotator cuff tear has occurred as a result of traumatic injury
• large or massive, retracted tears with chronic (more than 6- to 12- weeks) of symptoms in whom MRI and x-rays demonstrate the appearance of atrophy, upward migration of the humeral head, or the early signs of rotator cuff arthropathy.

• be in optimal health
• understand and accept the surgical alternatives, options, risks and benefits
• have discussed and or attempted non-operative measures to treat the problem (i.e. rehabilitation/physical therapy)
• have undergone a comprehensive examination, X-ray and usually MRI work-up to define the tear and evaluate the rest of the joint.

What are the most frequent and most serious risks of arthroscopic rotator cuff repair and shoulder surgery for rotator cuff tears, arthroscopic, minimally-invasive and open management? How common are they?

Adverse events following shoulder surgery are extremely rare, but they can not be completely eliminated.   The risks of arthroscopic rotator cuff repair include but are not limited to the following:

Infection, temporary or permanent injury to the nerves and blood vessels around the shoulder, permanent joint stiffness, recurrent tears of the rotator cuff, pain, allergic reactions to any implants or suture materials used to stabilize the joint, or the need for additional surgeries.  The anesthesia used during the procedure also has some risks, that can be addressed by the anesthesiologist.  The experienced and cautious surgical team uses special techniques to minimize all the above risks. 

If risks occur during or after arthroscopic rotator cuff repair and shoulder surgery for rotator cuff tears, arthroscopic, minimally-invasive and open management how are they managed?

Many of the risks of surgical stabilization can be effectively managed if they are promptly identified and treated. Infections may require a wash-out of the joint, and rarely require removal of any implanted materials.  Blood vessel or nerve injuries are rare, and most resolve spontaneously.  Occasionally, such an injury may require surgical repair.  Excessive stiffness of the joint is rare in the person who is cooperative with the postoperative rehabilitation program, and most of the stiffness will respond to exercises.  If a patient has questions or concerns about the “normal” course after surgery, the surgeon should be informed as soon as possible and be available to explain the expected course and outcome.

Surgery for Rotator cuff tears, arthroscopic, minimally-invasive and open management at the University of Washington

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